Objectives To evaluate the performance and cost effectiveness of the WHO recommendations of incorporating risk-assessment scores and population prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) into vaginal discharge syndrome (VDS) algorithms. Methods Non-pregnant women presenting with VDS were recruited at a non-governmental sexual health clinic in Sofia, Bulgaria. NG and CT were diagnosed by PCR and vaginal infections by microscopy. Risk factors for NG/CT were identified in multivariable analysis. Four algorithms based on different combinations of behavioural factors, clinical findings and vaginal microscopy were developed. Performance of each algorithm was evaluated for detecting vaginal and cervical infections separately. Cost effectiveness was based on cost per patient treated and cost per case correctly treated. Sensitivity analysis explored the influence of NG/CT prevalence on cost effectiveness. Results 60% (252/420) of women had genital infections, with 9.5% (40/423) having NG/CT. Factors associated with NG/CT included new and multiple sexual partners in the past 3 months, symptomatic partner, childlessness and $10 polymorphonuclear cells per field on vaginal microscopy. For NG/CT detection, the algorithm that relied solely on behavioural risk factors was less sensitive but more specific than those that included speculum examination or microscopy but had higher correct-treatment rate and lower over-treatment rates. The cost per true case treated using a combination of risk factors, speculum examination and microscopy was €24.08. A halving and tripling of NG/CT prevalence would have approximately the inverse impact on the cost-effectiveness estimates. Conclusions Management of NG/CT in Bulgaria was improved by the use of a syndromic approach that included risk scores. Approaches that did not rely on microscopy lost sensitivity but were more cost effective.

Early and late half-lives of hCG do not identify all women at risk for persistent ectopic pregnancy. To exclude persistent trophoblast, postoperative serum hCG determination should be performed until levels are undetectable.

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In utero RVT is not commonly suspected in the differential diagnosis of a renal mass in the fetus. To date, only six antenatal cases have been published. While the causes are diverse and the pathophysiologic mechanisms unclear, antenatal RVT is frequently associated with fetal distress. We report a new case of antenatal RVT, revealed by ultrasonography performed at 36 weeks' gestation for fetal distress, after an accidental electric shock 2 weeks earlier. CASE REPORTA 32 year old gravida 8 para 5 woman consulted the emergency department at 34 weeks' gestation after having received an electric shock. While mowing her lawn in bare feet, she accidentally grasped a partially unprotected area of her lawn mower's electric cable sheath. According to witnesses, her right hand firmly grasped the cable, after which she fell on her knees without losing consciousness. Her history suggested vertical flow of electric current from her right hand (entry point) to her bare feet (exit point), in that electric current travels to the area of lower resistance.She reported decreased fetal movements. The results of the obstetric examination were normal. Fetal well-being appeared normal, assessed by five cardiotocograms over a 24 h period and by fetal ultrasonography, which showed no pathologic conditions as compared to her 22 weeks' ultrasonography. No burn marks were observed. Her electrocardiogram showed a sinus tachycardia. She left the department after 24 h of observation, the fetal condition and hers considered normal.Two weeks later (36 weeks' of pregnancy), the patient returned to the emergency department, reporting an absence of fetal activity for the last 48 h. She also complained of pain in the fifth digit of her right hand, which was found to be the site of a punctiform third degree burn lesion. The patient was experiencing spontaneous uterine contractions, and a cardiotocogram revealed fetal tachycardia (170 beats/min), markedly reduced beat to beat variability, absence of accelerations, and sporadic late decelerations. The placenta, amniotic fluid index, and Doppler umbilical flow were all normal on sonographic

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